Service, training, mentorship: first report of an innovative education-support program to revitalize primary care social service in Chiapas, Mexico

Background: The Mexican mandatory year of social service following medical school, or pasantía, is designed to provide a safety net for the underserved. However, social service physicians (pasantes) are typically unpracticed, unsupervised, and unsupported. Significant demotivation, absenteeism, and underperformance typically plague the social service year. Objective: Compañeros en Salud (CES) aimed to create an education-support package to turn the pasantía into a transformative learning experience. Design: CES recruited pasantes to complete their pasantía in CES-supported Ministry of Health clinics in rural Chiapas. The program aims to: 1) train pasantes to more effectively deliver primary care, 2) expose pasantes to central concepts of global health and social medicine, and 3) foster career development of pasantes. Program components include supportive supervision, on-site mentorship, clinical information resources, monthly interactive seminars, and improved clinic function. We report quantitative and qualitative pasante survey data collected from February 2012 to August 2013 to discuss strengths and weaknesses of this program and its implications for the pasante workforce in Mexico. Results: Pasantes reported that their medical knowledge, and clinical and leadership skills all improved during the CES education-support program. Most pasantes felt the program had an overall positive effect on their career goals and plans, although their self-report of preparedness for the Mexican residency entrance exam (ENARM) decreased during the social service year. One hundred percent reported they were satisfied with the CES-supported pasantía experience and wished to help the poor and underserved in their careers. Conclusions: Education-support programs similar to the CES program may encourage graduating medical students to complete their social service in underserved areas, improve the quality of care provided by pasantes, and address many of the known shortcomings of the pasantía. Additional efforts should focus on developing a strategy to expand this education-support model so that more pasantes throughout Mexico can experience a transformative, career-building, social service year

"Adiós Bacteriemias": a multi-country quality improvement collaborative project to reduce the incidence of CLABSI in Latin American ICUs

Quality Problem: The incidence of central line-associated bloodstream infections (CLABSI) in Latin America has been estimated at 4.9 episodes per 1000 central line (CL) days, compared to a pooled incidence of 0.9 in the United States. CLABSI usually result from not adhering to standardized health procedures and can be prevented using evidence-based practices. Initial Assessment: The first phase of the ?Adiós Bacteriemias? Collaborative was implemented in 39 intensive care units (ICUs) from Latin America from September 2012 to September 2013 with a 56% overall reduction in the incidence of CLABSI. Choice of Solution: Bundles of care for the processes of insertion and maintenance of CLs have proven to be effective in the reduction of CLABSI across different settings. Implementation: Building on the results of the first phase, we implemented a second phase of the ?Adiós Bacteriemias? Collaborative between June 2014-July 2015. We adapted the Breakthrough Series (BTS) Collaborative model to guide the adoption of bundles of care for CLABSI prevention through virtual learning sessions and continuous feedback. Evaluation: Eighty-three ICUs from five Latin American countries actively reported process and outcome measures. The overall reduction in the CLABSI incidence rate was 22% (incidence rate 0.78; 95% CI 0.65, 0.95), from 2.58 episodes per 1000 CL days at baseline to 2.02 episodes per 1000 CL days (P < 0.01) during the intervention period. Lessons Learned: Adiós Bacteriemias was effective in reducing the incidence of CLABSI and improving the adherence to good practices for CL insertion and maintenance processes in participating ICUs in Latin America.Fil: Arrieta, Jafet. Harvard University. Harvard School of Public Health; Estados UnidosFil: Orrego, Carola. Fundacion Avedis Donabedian; EspañaFil: Macchiavello, Dolores. Instituto Alexander Fleming; ArgentinaFil: Mora, Nuria. Fundacion Avedis Donabedian; EspañaFil: Delgado, Pedro. Harvard University. Harvard School of Public Health; Estados UnidosFil: Giuffré, Carolina. Hospital Británico de Buenos Aires; ArgentinaFil: Garcia Elorrio, Ezequiel. Hospital Alemán; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Rodriguez, Viviana. Hospital Alemán; Argentin

Community health workers improve disease control and medication adherence among patients with diabetes and/or hypertension in Chiapas, Mexico: an observational stepped-wedge study

Background: Non-communicable diseases (NCDs) contribute greatly to morbidity and mortality in low-income and middle-income countries (LMICs). Community health workers (CHWs) may improve disease control and medication adherence among patients with NCDs in LMICs, but data are lacking. We assessed the impact of a CHW-led intervention on disease control and adherence among patients with diabetes and/or hypertension in Chiapas, Mexico. Methods: We conducted a prospective observational study among adult patients with diabetes and/or hypertension, in the context of a stepped-wedge roll-out of a CHW-led intervention. We measured self-reported adherence to medications, blood pressure and haemoglobin A1c at baseline and every 3 months, timed just prior to expansion of the intervention to a new community. We conducted individual-level mixed effects analyses of study data, adjusting for time and clustering by patient and community. Findings: We analysed 108 patients. The CHW-led intervention was associated with a twofold increase in the odds of disease control (OR 2.04, 95% CI 1.15 to 3.62). It was also associated with optimal adherence assessed by 30-day recall (OR 1.86; 95% CI 1.15 to 3.02) and a positive self-assessment of adherence behaviour (OR 2.29; 95% CI 1.26 to 4.15), but not by 5-day recall. Interpretation A CHW-led adherence intervention was associated with disease control and adherence among adults with diabetes and/or hypertension. This study supports a role of CHWs in supplementing comprehensive primary care for patients with NCDs in LMICs. Trial registration number NCT02549495

Understanding Depression in Rural Chiapas: Contextualizing Quantitative Measures and Patients’ Experiences

Depressive disorders are highly prevalent in primary care settings and are associated with severe physical and social impairment. However, it is a challenge for primary health care providers to identify depressive disorders early. The Patient Health Questionnaire-2 (PHQ-2) and PHQ-9 have been widely used for screening and diagnosis of depression in primary care settings. We used a mixed methods design to assess the validity of the PHQ-9 for diagnosis of depression; to assess the sensitivity and specificity of the PHQ-2 for screening of depression; and to characterize the experience of participants living with depression in rural Spanish-speaking settings. The study was conducted in a rural community of Chiapas, Mexico. Quantitative data was collected using the PHQ-2, the PHQ-9, and the WHO Quality of Life BREF (WHOQOL-BREF) scales during an active case finding activity (n=223). Qualitative data was collected through semi-structured interviews (n=20). The internal consistency of the PHQ-9 was good (Cronbach’s alpha >= 0.8) for the overall PHQ-9 and by subgroups. The PHQ-9 also had good construct validity: participants with a PHQ-9 diagnosis of depression had statistically significantly lower scores on the overall WHOQOL-BREF scale and each of its domains. The optimal PHQ-2 cutpoint score for screening of depression when compared with the PHQ-9 was 3 (sensitivity 80.00%, specificity 86.88%). Four main categories were derived from the qualitative analysis, including life events as triggers for depression; common feelings of sadness and desesperación, thinking too much, and somatization; a experience seeking care influenced by the local conceptualization of depressive illness, the lack of availability of health services, and physicians’ failure to recognize symptoms of depressive illness; and a experience of accompaniment perceived as therapeutic. Evidence supports the validity of the PHQ-2 and PHQ-9 to screen and diagnose for depression in rural Spanish-speaking populations, and the association of depression with lower quality of life. The study findings highlight the role of the local context on triggering depression and influencing care-seeking behavior, and on how depressive illness is experienced by patients. Therefore, in order to improve mental health care delivery strategies, strategies and interventions should be adapted to the local context

The COVID-19 pandemic: A call to action for health systems in Latin America to strengthen quality of care

The Covid-19 and other recent pandemics has highlighted existing weakness in health systems across the Latin-America and the Caribbean (LAC) region to effectively prepare for and respond to Public Health Emergencies. It has been stated that quality of care will be among the most influential factors on Covid 19 mortality rates and low systems performance is the common case in these countries. More comprehensive and system level strategies are required to address the challenges. These must focus on redesigning and strengthening health systems to make them more resilient to the changing needs of populations and based on quality improvement methods that have shown rigorously evaluated positive effects in previous local and regional experiences. A call to action is being made by the Latin American Consortium for Quality, Patient Safety and Innovation (CLICSS) and they provide specific recommendations for decision makers.Fil: Garcia Elorrio, Ezequiel. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Jafet, Arrieta. Institute For Healthcare Improvement; Estados UnidosFil: Hugo, Arce. Fundación Barceló; EspañaFil: Pedro, Delgado. Institute For Healthcare Improvement; Estados UnidosFil: Ana Maria, Malik. Getulio Vargas Foundation ; BrasilFil: Carola, Orrego Villagran. Fundació Avedis Donavedian; EspañaFil: Sofia, Rincon. No especifíca;Fil: Odet, Sarabia. Universidad Nacional Autónoma de México; MéxicoFil: Teresa, Tono. No especifíca;Fil: Jorge, Hermida. Foundation For Health Services Research And Management; EcuadorFil: Enrique, Ruelas Barajas. International Institute For Health Futures; Méxic

Validity and Utility of the Patient Health Questionnaire (PHQ)‐2 and PHQ‐9 for Screening and Diagnosis of Depression in Rural Chiapas, Mexico: A Cross‐Sectional Study

Background: Depressive disorders are frequently under diagnosed in resource‐limited settings because of lack of access to mental health care or the inability of healthcare providers to recognize them. The Patient Health Questionnaire (PHQ)‐2 and the PHQ‐9 have been widely used for screening and diagnosis of depression in primary care settings; however, the validity of their use in rural, Spanish‐speaking populations is unknown. Method We used a cross‐sectional design to assess the psychometric properties of the PHQ‐9 for depression diagnosis and estimated the sensitivity and specificity of the PHQ‐2 for depression screening. Data were collected from 223 adults in a rural community of Chiapas, Mexico, using the PHQ‐2, the PHQ‐9, and the World Health Organization Quality of Life BREF Scale (WHOQOL‐ BREF). Results: Confirmatory factor analysis suggested that the 1‐factor structure fit reasonably well. The internal consistency of the PHQ‐9 was good (Cronbach's alpha > = 0.8) overall and for subgroups defined by gender, literacy, and age. The PHQ‐9 demonstrated good predictive validity: Participants with a PHQ‐9 diagnosis of depression had lower quality of life scores on the overall WHOQOL‐BREF Scale and each of its domains. Using the PHQ‐9 results as a gold standard, the optimal PHQ‐2 cutoff score for screening of depression was 3 (sensitivity 80.00%, specificity 86.88%, area under receiver operating characteristic curve = 0.89; 95% confidence interval [0.84, 0.94]). Conclusion: The PHQ‐2 and PHQ‐9 demonstrated good psychometric properties, suggesting their potential benefit as tools for depression screening and diagnosis in rural, Spanish‐speaking populations